IC 12-15-11.5
Chapter 11.5. Lake County Disproportionate Share Hospitals
IC 12-15-11.5-0.5 Chapter not applicable to certain managed care contractors
Sec. 0.5. This chapter does not apply to a managed care contractor
that, on or before July 1, 2000, did not directly contract with a
hospital (as defined in section 1 of this chapter) for the provision of
services under the office's managed care program. As added by P.L.141-2001, SEC.1.
IC 12-15-11.5-1 "Hospital" defined
Sec. 1. As used in this chapter, "hospital" refers to an acute care
hospital provider that:
(1) is licensed under IC 16-21;
(2) qualifies as a disproportionate share hospital under
IC 12-15-16; and
(3) is the sole disproportionate share hospital in a city located
in a county having a population of more than four hundred
thousand (400,000) but less than seven hundred thousand
(700,000). As added by P.L.142-2000, SEC.2.
IC 12-15-11.5-2 Hospital as contracted provider to eligible individuals
Sec. 2. The office's managed care contractor shall regard a
hospital as a contracted provider in the office's managed care
services program, which provides a capitated prepayment managed
care system, for the provision of medical services to each individual
who:
(1) is eligible to receive services under IC 12-15 and has
enrolled in the office's managed care services program;
(2) resides in the same city in which the hospital is located; and
(3) has selected a primary care provider who:
(A) is a contracted provider with the office's managed care
contractor; and
(B) has medical staff privileges at the hospital. As added by P.L.142-2000, SEC.2. Amended by P.L.141-2001,
SEC.2.
IC 12-15-11.5-3
Repealed
(Repealed by P.L.145-2005, SEC.30.)
IC 12-15-11.5-3.1
Repealed
(Repealed by P.L.1-2007, SEC.248.)
IC 12-15-11.5-4
Repealed
(Repealed by P.L.1-2002, SEC.172.)
IC 12-15-11.5-4.1
Repealed
(Repealed by P.L.145-2005, SEC.30.)
IC 12-15-11.5-4.2
Repealed
(Repealed by P.L.1-2007, SEC.248.)
IC 12-15-11.5-5
Repealed
(Repealed by P.L.1-2002, SEC.172.)
IC 12-15-11.5-6 Claim for reimbursement treated as disputed claim
Sec. 6. A claim for reimbursement for services shall be treated as
a disputed claim under this chapter if:
(1) it is submitted within one hundred twenty (120) days after
the date that services are rendered;
(2) it is denied by the managed care contractor;
(3) the hospital submits a written notice of dispute for the claim
to the managed care contractor not more than sixty (60) days
after the receipt of the denial notice;
(4) it is appealed in accordance with the managed care
contractor's internal appeals process; and
(5) payment for the claim is denied by the managed care
contractor following its internal appeals process. As added by P.L.142-2000, SEC.2.
IC 12-15-11.5-7 Conclusion of appeal
Sec. 7. The office's managed care contractor must conclude an
appeal under section 6(4) of this chapter and notify the hospital of its
decision not more than thirty-five (35) days after the managed care
contractor receives a notice from the hospital disputing the managed
care contractor's denial of a claim. As added by P.L.142-2000, SEC.2.
IC 12-15-11.5-8 Dispute resolution procedure requirements
Sec. 8. (a) A contract entered into by a hospital with the office's
managed care contractor for the provision of services under the
office's managed care services program must include a dispute
resolution procedure for all disputed claims. Unless agreed to in
writing by the hospital and the office's managed care contractor, the
dispute resolution procedure must include the following
requirements:
(1) That submission of disputed claims must be made to an
independent arbitrator selected under subsection (b).
(2) Each claim must set forth with specificity the issues to be
arbitrated, the amount involved, and the relief sought.
(3) That the hospital and the office's managed care contractor
shall attempt in good faith to resolve all disputed claims.
(4) The hospital shall submit to the arbitrator any claims that
remain in dispute sixty (60) calendar days after the hospital
receives written notice as provided under section 7 of this
chapter.
(5) That resolution of disputes by the arbitrator must occur not
later than ninety (90) calendar days after submission of disputed
claims to the arbitrator, unless the parties mutually agree
otherwise.
(6) That determinations of the arbitrator are final and binding
and not subject to any appeal or review procedure.
(7) That the arbitrator does not have the authority to award any
punitive or exemplary damages or to vary or ignore the terms of
any contract between the parties and shall be bound by
controlling law.
(8) That judgment upon the award rendered by the arbitrator
may be entered and enforced in and is subject to the jurisdiction
of a court with jurisdiction in Indiana.
(9) That the cost of the arbitrator must be shared equally by the
parties, and each party must bear its own attorney and witness
fees.
(b) The parties to a contract described in subsection (a) shall
mutually agree on an independent arbitrator, or, if the parties are
unable to reach agreement on an independent arbitrator, the
following procedure must be followed:
(1) Each party shall select an independent representative, and
the independent representatives shall select a panel of three (3)
independent arbitrators who have experience in institutional and
professional health care delivery practices and procedures and
have had no prior dealing with either party other than as an
arbitrator.
(2) The parties will each strike one (1) arbitrator from the panel
selected under subdivision (1), and the remaining arbitrator
serves as the arbitrator of the disputed claims under subsection
(a).
(3) The procedures for selecting an arbitrator under this section
must be completed not later than twenty (20) calendar days after
the hospital provides written notice of at least one (1) disputed
claim. As added by P.L.142-2000, SEC.2.
IC 12-15-11.5-9 Arbitration process to be followed for disputed claims between
hospital and managed care contractor
Sec. 9. The arbitration process described in section 8 of this
chapter shall also be followed for resolution of disputed claims
between a hospital and the office's managed care contractor, if the
hospital is not a contracted provider in the office's managed health
care services program. As added by P.L.142-2000, SEC.2.
IC 12-15-11.5
Chapter 11.5. Lake County Disproportionate Share Hospitals
IC 12-15-11.5-0.5 Chapter not applicable to certain managed care contractors
Sec. 0.5. This chapter does not apply to a managed care contractor
that, on or before July 1, 2000, did not directly contract with a
hospital (as defined in section 1 of this chapter) for the provision of
services under the office's managed care program. As added by P.L.141-2001, SEC.1.
IC 12-15-11.5-1 "Hospital" defined
Sec. 1. As used in this chapter, "hospital" refers to an acute care
hospital provider that:
(1) is licensed under IC 16-21;
(2) qualifies as a disproportionate share hospital under
IC 12-15-16; and
(3) is the sole disproportionate share hospital in a city located
in a county having a population of more than four hundred
thousand (400,000) but less than seven hundred thousand
(700,000). As added by P.L.142-2000, SEC.2.
IC 12-15-11.5-2 Hospital as contracted provider to eligible individuals
Sec. 2. The office's managed care contractor shall regard a
hospital as a contracted provider in the office's managed care
services program, which provides a capitated prepayment managed
care system, for the provision of medical services to each individual
who:
(1) is eligible to receive services under IC 12-15 and has
enrolled in the office's managed care services program;
(2) resides in the same city in which the hospital is located; and
(3) has selected a primary care provider who:
(A) is a contracted provider with the office's managed care
contractor; and
(B) has medical staff privileges at the hospital. As added by P.L.142-2000, SEC.2. Amended by P.L.141-2001,
SEC.2.
IC 12-15-11.5-3
Repealed
(Repealed by P.L.145-2005, SEC.30.)
IC 12-15-11.5-3.1
Repealed
(Repealed by P.L.1-2007, SEC.248.)
IC 12-15-11.5-4
Repealed
(Repealed by P.L.1-2002, SEC.172.)
IC 12-15-11.5-4.1
Repealed
(Repealed by P.L.145-2005, SEC.30.)
IC 12-15-11.5-4.2
Repealed
(Repealed by P.L.1-2007, SEC.248.)
IC 12-15-11.5-5
Repealed
(Repealed by P.L.1-2002, SEC.172.)
IC 12-15-11.5-6 Claim for reimbursement treated as disputed claim
Sec. 6. A claim for reimbursement for services shall be treated as
a disputed claim under this chapter if:
(1) it is submitted within one hundred twenty (120) days after
the date that services are rendered;
(2) it is denied by the managed care contractor;
(3) the hospital submits a written notice of dispute for the claim
to the managed care contractor not more than sixty (60) days
after the receipt of the denial notice;
(4) it is appealed in accordance with the managed care
contractor's internal appeals process; and
(5) payment for the claim is denied by the managed care
contractor following its internal appeals process. As added by P.L.142-2000, SEC.2.
IC 12-15-11.5-7 Conclusion of appeal
Sec. 7. The office's managed care contractor must conclude an
appeal under section 6(4) of this chapter and notify the hospital of its
decision not more than thirty-five (35) days after the managed care
contractor receives a notice from the hospital disputing the managed
care contractor's denial of a claim. As added by P.L.142-2000, SEC.2.
IC 12-15-11.5-8 Dispute resolution procedure requirements
Sec. 8. (a) A contract entered into by a hospital with the office's
managed care contractor for the provision of services under the
office's managed care services program must include a dispute
resolution procedure for all disputed claims. Unless agreed to in
writing by the hospital and the office's managed care contractor, the
dispute resolution procedure must include the following
requirements:
(1) That submission of disputed claims must be made to an
independent arbitrator selected under subsection (b).
(2) Each claim must set forth with specificity the issues to be
arbitrated, the amount involved, and the relief sought.
(3) That the hospital and the office's managed care contractor
shall attempt in good faith to resolve all disputed claims.
(4) The hospital shall submit to the arbitrator any claims that
remain in dispute sixty (60) calendar days after the hospital
receives written notice as provided under section 7 of this
chapter.
(5) That resolution of disputes by the arbitrator must occur not
later than ninety (90) calendar days after submission of disputed
claims to the arbitrator, unless the parties mutually agree
otherwise.
(6) That determinations of the arbitrator are final and binding
and not subject to any appeal or review procedure.
(7) That the arbitrator does not have the authority to award any
punitive or exemplary damages or to vary or ignore the terms of
any contract between the parties and shall be bound by
controlling law.
(8) That judgment upon the award rendered by the arbitrator
may be entered and enforced in and is subject to the jurisdiction
of a court with jurisdiction in Indiana.
(9) That the cost of the arbitrator must be shared equally by the
parties, and each party must bear its own attorney and witness
fees.
(b) The parties to a contract described in subsection (a) shall
mutually agree on an independent arbitrator, or, if the parties are
unable to reach agreement on an independent arbitrator, the
following procedure must be followed:
(1) Each party shall select an independent representative, and
the independent representatives shall select a panel of three (3)
independent arbitrators who have experience in institutional and
professional health care delivery practices and procedures and
have had no prior dealing with either party other than as an
arbitrator.
(2) The parties will each strike one (1) arbitrator from the panel
selected under subdivision (1), and the remaining arbitrator
serves as the arbitrator of the disputed claims under subsection
(a).
(3) The procedures for selecting an arbitrator under this section
must be completed not later than twenty (20) calendar days after
the hospital provides written notice of at least one (1) disputed
claim. As added by P.L.142-2000, SEC.2.
IC 12-15-11.5-9 Arbitration process to be followed for disputed claims between
hospital and managed care contractor
Sec. 9. The arbitration process described in section 8 of this
chapter shall also be followed for resolution of disputed claims
between a hospital and the office's managed care contractor, if the
hospital is not a contracted provider in the office's managed health
care services program. As added by P.L.142-2000, SEC.2.
IC 12-15-11.5
Chapter 11.5. Lake County Disproportionate Share Hospitals
IC 12-15-11.5-0.5 Chapter not applicable to certain managed care contractors
Sec. 0.5. This chapter does not apply to a managed care contractor
that, on or before July 1, 2000, did not directly contract with a
hospital (as defined in section 1 of this chapter) for the provision of
services under the office's managed care program. As added by P.L.141-2001, SEC.1.
IC 12-15-11.5-1 "Hospital" defined
Sec. 1. As used in this chapter, "hospital" refers to an acute care
hospital provider that:
(1) is licensed under IC 16-21;
(2) qualifies as a disproportionate share hospital under
IC 12-15-16; and
(3) is the sole disproportionate share hospital in a city located
in a county having a population of more than four hundred
thousand (400,000) but less than seven hundred thousand
(700,000). As added by P.L.142-2000, SEC.2.
IC 12-15-11.5-2 Hospital as contracted provider to eligible individuals
Sec. 2. The office's managed care contractor shall regard a
hospital as a contracted provider in the office's managed care
services program, which provides a capitated prepayment managed
care system, for the provision of medical services to each individual
who:
(1) is eligible to receive services under IC 12-15 and has
enrolled in the office's managed care services program;
(2) resides in the same city in which the hospital is located; and
(3) has selected a primary care provider who:
(A) is a contracted provider with the office's managed care
contractor; and
(B) has medical staff privileges at the hospital. As added by P.L.142-2000, SEC.2. Amended by P.L.141-2001,
SEC.2.
IC 12-15-11.5-3
Repealed
(Repealed by P.L.145-2005, SEC.30.)
IC 12-15-11.5-3.1
Repealed
(Repealed by P.L.1-2007, SEC.248.)
IC 12-15-11.5-4
Repealed
(Repealed by P.L.1-2002, SEC.172.)
IC 12-15-11.5-4.1
Repealed
(Repealed by P.L.145-2005, SEC.30.)
IC 12-15-11.5-4.2
Repealed
(Repealed by P.L.1-2007, SEC.248.)
IC 12-15-11.5-5
Repealed
(Repealed by P.L.1-2002, SEC.172.)
IC 12-15-11.5-6 Claim for reimbursement treated as disputed claim
Sec. 6. A claim for reimbursement for services shall be treated as
a disputed claim under this chapter if:
(1) it is submitted within one hundred twenty (120) days after
the date that services are rendered;
(2) it is denied by the managed care contractor;
(3) the hospital submits a written notice of dispute for the claim
to the managed care contractor not more than sixty (60) days
after the receipt of the denial notice;
(4) it is appealed in accordance with the managed care
contractor's internal appeals process; and
(5) payment for the claim is denied by the managed care
contractor following its internal appeals process. As added by P.L.142-2000, SEC.2.
IC 12-15-11.5-7 Conclusion of appeal
Sec. 7. The office's managed care contractor must conclude an
appeal under section 6(4) of this chapter and notify the hospital of its
decision not more than thirty-five (35) days after the managed care
contractor receives a notice from the hospital disputing the managed
care contractor's denial of a claim. As added by P.L.142-2000, SEC.2.
IC 12-15-11.5-8 Dispute resolution procedure requirements
Sec. 8. (a) A contract entered into by a hospital with the office's
managed care contractor for the provision of services under the
office's managed care services program must include a dispute
resolution procedure for all disputed claims. Unless agreed to in
writing by the hospital and the office's managed care contractor, the
dispute resolution procedure must include the following
requirements:
(1) That submission of disputed claims must be made to an
independent arbitrator selected under subsection (b).
(2) Each claim must set forth with specificity the issues to be
arbitrated, the amount involved, and the relief sought.
(3) That the hospital and the office's managed care contractor
shall attempt in good faith to resolve all disputed claims.
(4) The hospital shall submit to the arbitrator any claims that
remain in dispute sixty (60) calendar days after the hospital
receives written notice as provided under section 7 of this
chapter.
(5) That resolution of disputes by the arbitrator must occur not
later than ninety (90) calendar days after submission of disputed
claims to the arbitrator, unless the parties mutually agree
otherwise.
(6) That determinations of the arbitrator are final and binding
and not subject to any appeal or review procedure.
(7) That the arbitrator does not have the authority to award any
punitive or exemplary damages or to vary or ignore the terms of
any contract between the parties and shall be bound by
controlling law.
(8) That judgment upon the award rendered by the arbitrator
may be entered and enforced in and is subject to the jurisdiction
of a court with jurisdiction in Indiana.
(9) That the cost of the arbitrator must be shared equally by the
parties, and each party must bear its own attorney and witness
fees.
(b) The parties to a contract described in subsection (a) shall
mutually agree on an independent arbitrator, or, if the parties are
unable to reach agreement on an independent arbitrator, the
following procedure must be followed:
(1) Each party shall select an independent representative, and
the independent representatives shall select a panel of three (3)
independent arbitrators who have experience in institutional and
professional health care delivery practices and procedures and
have had no prior dealing with either party other than as an
arbitrator.
(2) The parties will each strike one (1) arbitrator from the panel
selected under subdivision (1), and the remaining arbitrator
serves as the arbitrator of the disputed claims under subsection
(a).
(3) The procedures for selecting an arbitrator under this section
must be completed not later than twenty (20) calendar days after
the hospital provides written notice of at least one (1) disputed
claim. As added by P.L.142-2000, SEC.2.
IC 12-15-11.5-9 Arbitration process to be followed for disputed claims between
hospital and managed care contractor
Sec. 9. The arbitration process described in section 8 of this
chapter shall also be followed for resolution of disputed claims
between a hospital and the office's managed care contractor, if the
hospital is not a contracted provider in the office's managed health
care services program. As added by P.L.142-2000, SEC.2.
